Register for Online Proxy Access

Register for Online Proxy Access

This form is for parents, guardians and carers requesting 3rd party access to another patients online medical records.

  • Proxy Online Access To Medical Records - Consent Form

    Proxy access you will allow you to book appointments, order repeat prescriptions, and have access to the elements of the medical record that have been released for online access.

    The parent, guardian or carer must show proof of ID and proof of right (birth certificate, adoption certificate/ power of attorney etc) at the time of requesting proxy access.

    If there are any limitations on access to the patient or their information imposed by Court or Social Services it must be declared

     

    Confidentiality and Young people

    When the patient turns 12 proxy access will be reviewed and consent from them will be required. When turning 16 proxy access will be removed and direct access granted to the patient.

    In certain situations it may be appropriate for proxy access to be maintained after the patient turns 16. This will be discussed and approved on an individual basis.

    I understand and agree with each of the following statements

  • Patient Details

    Please fill out the deatils of the person who's medical records are being accessed

    Date of Birth
    For example, 15 3 1984

  • Representative's Details

    Please fill out the deatils of the representative who wishes to have proxy access 

    Date of birth
    For example, 15 3 1984

  • Documents Required

    Once we have received your application we will contact you to provide the following documents.

    - Photo ID of the representative (Passport, driving licence etc.)

    - Proof of right to access (Birth certificate, adoption certificate, power of attorney etc.)

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Page last reviewed: 14 February 2022
Page created: 16 April 2020